Cycle 1
Health 2025-01-16 · Fire 2025-01-16
12 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Lauderdale Lakes, FL
St Johns Nursing Center
3-star overall rating with 3-star inspections with $25,155 in total fines with 12 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
3075 Nw 35th Ave, Lauderdale Lakes, FL
(954) 739-6233
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
181
Certified beds
Average residents
169
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1980-09-19
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.68
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.75
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.39
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.82
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.43
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.54
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.49
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.73
CMS adjusted RN staffing hours
Adjusted total hours
4.06
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
18%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,105
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.26
Composite VBP score used to determine payment impact.
Payment multiplier
0.9942
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
0
Baseline 6.93% · Performance 8.43% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
10
Baseline 30.77% · Performance 16.92% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
2.38
Baseline 4.13 hours · Performance 3.75 hours · Measure score 2.38 · Achievement 2.38 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.15% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 59 · Observed rate 15.25% · Lower 95% interval 7.08% |
| Discharge to community | 42.94% |
50.57%
7.6 pts worse
|
No Different than the National Rate · Eligible stays 64 · Observed rate 31.25% · Lower 95% interval 33.45% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.11% |
95.27%
2.8 pts better
|
Numerator 52 · Denominator 53 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 53 |
| Discharge self-care score | 30% |
53.69%
23.7 pts worse
|
Numerator 9 · Denominator 30 |
| Discharge mobility score | 33.33% |
50.94%
17.6 pts worse
|
Numerator 10 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 53 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.43% |
7.12%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 32 · Observed rate 15.63% · Lower 95% interval 3.99% |
| Staff COVID-19 vaccination coverage | 1.21% |
8.2%
7 pts worse
|
Numerator 4 · Denominator 330 |
| Staff flu vaccination coverage | 90.31% |
42%
48.3 pts better
|
Numerator 317 · Denominator 351 |
| Discharge function score | 33.33% |
56.45%
23.1 pts worse
|
Numerator 10 · Denominator 30 |
| Transfer of health information to provider | 86.36% |
95.95%
9.6 pts worse
|
Numerator 19 · Denominator 22 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 3.7% |
25.2%
21.5 pts worse
|
Numerator 1 · Denominator 27 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.8%
2.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
99.2%
0.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.7% |
2.6%
1.9 pts better
|
3.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
3.7%
3.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 5.0% |
5.9%
0.9 pts better
|
5.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 6.9% · Q3 1.8% · Q4 3.4% · 4Q avg 5.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.2% |
15.7%
6.5 pts better
|
19.6%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 12.8% · Q3 6.1% · Q4 5.1% · 4Q avg 9.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.3% |
9.8%
4.5 pts better
|
16.7%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 6.7% · Q3 4.0% · Q4 2.8% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 13.6% |
11.7%
1.9 pts worse
|
16.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.5% · Q2 4.0% · Q3 15.8% · Q4 10.2% · 4Q avg 13.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.3% |
9.8%
3.5 pts better
|
14.9%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.7% · Q2 5.1% · Q3 3.1% · Q4 3.0% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
0.4%
0.4 pts worse
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.7% · Q3 0.6% · Q4 1.2% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
0.8%
0.1 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.7% · Q3 0.7% · Q4 0.8% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 6.2% |
12.5%
6.3 pts better
|
19.8%
13.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 6.8% · Q3 1.6% · Q4 1.6% · 4Q avg 6.2% |
| Percentage of long-stay residents with pressure ulcers | 2.0% |
5.1%
3.1 pts better
|
5.1%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 3.8% · Q3 1.3% · Q4 1.9% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.3%
5.7 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.5% |
9.3%
0.8 pts better
|
12.0%
3.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.5% · Observed 10.0% · Expected 13.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.5%
1.1 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.0% · Q3 0.5% · Q4 0.5% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.7%
5.3 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 43.1% |
26.2%
16.9 pts worse
|
23.9%
19.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 43.1% · Observed 60.0% · Expected 33.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-21 · Fire 2023-09-21
4 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2022-05-26 · Fire 2022-05-26
10 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-06-24
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-06-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-24
E · Potential for more than minimal harm
2025-01-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-02-15
D · Potential for more than minimal harm
2025-01-16
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-02-15
D · Potential for more than minimal harm
2025-01-16
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-02-15
D · Potential for more than minimal harm
2025-01-16
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-02-15
D · Potential for more than minimal harm
2023-09-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-21
D · Potential for more than minimal harm
2023-09-21
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-10-21
D · Potential for more than minimal harm
2023-09-21
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-10-21
D · Potential for more than minimal harm
2022-05-26
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-06-24
D · Potential for more than minimal harm
2022-05-26
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-06-24
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-01-16
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-01-16
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-01-16
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-01-16
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-01-16
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-01-16
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-01-16
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-01-16
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-01-16
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-01-16
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-01-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-01-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-10
G · Actual harm
2023-09-21
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-10-21
G · Actual harm
2023-09-21
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-10-21
D · Potential for more than minimal harm
2023-09-21
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-10-21
D · Potential for more than minimal harm
2023-09-21
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-10-21
D · Potential for more than minimal harm
2022-05-26
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-06-24
D · Potential for more than minimal harm
2022-05-26
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2022-06-24
D · Potential for more than minimal harm
2022-05-26
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-06-24
D · Potential for more than minimal harm
2022-05-26
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-06-24
D · Potential for more than minimal harm
2022-05-26
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-06-24
D · Potential for more than minimal harm
2022-05-26
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-06-24
D · Potential for more than minimal harm
2022-05-26
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-06-24
D · Potential for more than minimal harm
2022-05-26
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-06-24
D · Potential for more than minimal harm
2022-05-26
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-06-24
D · Potential for more than minimal harm
2022-05-26
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2022-06-24
Penalties and ownership
What sits behind the stars
$25,155
2023-09-21
Fine
Fine · fine $25,155
Fine
Ownership
Archdiocese Of Miami Inc
5% Or Greater Indirect Ownership Interest · Organization
St Johns Rehabilitation Hospital And Nursing Center Inc
5% Or Greater Direct Ownership Interest · Organization
Bailey, Rosemarie
Operational/Managerial Control · Individual
Catholic Health Services Inc
Operational/Managerial Control · Organization
Frick, Mary
Corporate Officer · Individual
Jules, Clinton
Operational/Managerial Control · Individual
Wilson, Laura
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Palms Care Center And Rehab
Lauderdale Lakes, FL
3-star overall rating with 2-star inspections with $11,517 in total fines with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Life Care Center At Inverrary
Lauderhill, FL
4-star overall rating with 3-star inspections with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Nspire Healthcare Lauderhill
Lauderhill, FL
3-star overall rating with 3-star inspections with 14 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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